Patient Registration Form

Atlantic Podiatry Center LLC
Dr. Rahul Gor DPM
14201 Laurel Park Drive, 102A Laurel, MD 20707
Tel: 301-604-9793 Fax: 888-272-4284

Name*

First NameMiddle NameLast Name

Date of Birth*

Gender

Telephone Number:      Phone Number
Alternative Number:      Phone Number
Contact Address:
Street Address
Apt/Suite/#
City   State   Zip

Preferred Email:   Email

Method of Contact for Reminders and updates :
Phone/Textt Email      Either
By checking this, you agree to receive txt/phone messages from Atlantic Podiatry Center, Reply STOP to Opt out, Reply HELP for help. Message frequency varies. Message data rates apply, carriers aren't liable for delayed/undeliverable messages.

Emergency Contact Person Name and Tel:

Payment Method :    INSURANCE            Cash   Worker's Comp

SOCIAL SECURITY NUMBER:

Insurance Name:

Insurance Id:

Primary Insured: Leave blank if self

Primary Insured DOB:    Leave Blank if self

Power of attorney/Guardian if any list name, address, tel number:
Name         address

Primary Care Physician and their Tel Number:

PREFERRED PHARMACY:
Phone:

WHO CAN WE RELEASE YOUR MEDICAL INFORMATION TO (NAME, TEL NO. RELATIONSHIP)
1._   Type a label________________________________________________________________
2.   Type a label   _______________________________________________________________
3.   Type a label   ___________________________________________________________________

MEDICARE HISTORY-PLEASE BE AS ACCURATE AS POSSIBLE

What is your present foot concern?


Date of Injury (if applicable):


How long have you had the concern?


What have you tried treat the condition?


Please list any prior foot care/surgery:

Is there any other issue we should know about?

ALLERGIES (VERY IMPORTANT TO LIST)

LIST ALL ALLERGIES DRUGS, CHEMICAL, FOOD, ENVIRONMENTAL

Are you on Blood Thinners?
YES   NO

Issues with Local Anesthetics?


Any issues/intolerance with Pain Killers?
   Type a label

Past Medical History

ANY OTHER MEDICAL CONDITIONS/SURGERIES WE SHOULD BE AWARE OF?

PLEASE LIST ANY RELEVANT FAMILY HX AND THE RELATIVE WHO HAS/HAD IT.

DO YOU SMOKE?     NEVER   EX SMOKER   CURRENT SMOKER
IF YOU SMOKE HOW MUCH?

USE OF ALCOHOL:   NEVER   SOCIAL   DAILY   HEAVY

DRUGS:   NO   YES
IF YES TYPE/FREQUENCY:

HEIGHT:   Type a label   WT :      SHOE SIZE:   Type a label

AUTHORIZATION, TREATMENT, ASSIGNMENT OF INSURANCE
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Atlantic Podiatry Center LLC/Dr. Gor
for any services furnished to me by that physician. I authorize any holder of medical information about me to release to the Health
Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related
services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay
the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or
electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare
assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the
patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon
the charge determination of the Medicare carrier.

I hereby give the Atlantic Podiatry Center LLC (APC)/Dr. Gor and its staff members permission to treat my feet and/or
ankle disorders. I, the undersigned, have insurance coverage with and assign directly to APC/Dr. Gor all medical benefits,
if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges
whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the
payment of benefits. I authorize the use of this signature on all my insurance submissions. I may receive a copy of Notice
of Privacy Practices and I have read (or had the opportunity to read) and understand the notice posted in the office.

NamePatient/POA/Guardian/Insured First Name Last Name
Date: Date

YOU MAY UPLOAD INSURANCE CARDS, MEDS LIST, OR ANY REFERRALS HERE